ICD-10 Diagnosis Code S06.309S

Unsp focal TBI w LOC of unsp duration, sequela

Diagnosis Code S06.309S

ICD-10: S06.309S
Short Description: Unsp focal TBI w LOC of unsp duration, sequela
Long Description: Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, sequela
This is the 2018 version of the ICD-10-CM diagnosis code S06.309S

Valid for Submission
The code S06.309S is valid for submission for HIPAA-covered transactions.

Code Classification
  • Injury, poisoning and certain other consequences of external causes (S00–T98)
    • Injuries to the head (S00-S09)
      • Intracranial injury (S06)

Information for Medical Professionals

Convert to ICD-9 Additional informationCallout TooltipGeneral Equivalence Map
The ICD-10 and ICD-9 GEMs are used to facilitate linking between the diagnosis codes in ICD-9-CM and the new ICD-10-CM code set. The GEMs are the raw material from which providers, health information vendors and payers can derive specific applied mappings to meet their needs.

Present on Admission (POA) Additional informationCallout TooltipPresent on Admission
The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement.

The code S06.309S is exempt from POA reporting.

  • Brain injury without open intracranial wound AND with brief loss of consciousness
  • Closed fracture of base of skull with intracranial hemorrhage
  • Closed fracture of vault of skull with intracranial hemorrhage
  • Closed skull fracture with intracranial hemorrhage
  • Closed skull fracture with intracranial hemorrhage
  • Hind brain laceration with open intracranial wound
  • Hypothalamic injury
  • Intracranial hemorrhage following injury with brief loss of consciousness
  • Intracranial hemorrhage following injury with open intracranial wound
  • Intracranial hemorrhage following injury without open intracranial wound AND with brief loss of consciousness

Information for Patients

Traumatic Brain Injury

Also called: Acquired brain injury, TBI

Traumatic brain injury (TBI) happens when a bump, blow, jolt, or other head injury causes damage to the brain. Every year, millions of people in the U.S. suffer brain injuries. More than half are bad enough that people must go to the hospital. The worst injuries can lead to permanent brain damage or death. Half of all TBIs are from motor vehicle accidents. Military personnel in combat zones are also at risk.

Symptoms of a TBI may not appear until days or weeks following the injury. A concussion is the mildest type. It can cause a headache or neck pain, nausea, ringing in the ears, dizziness, and tiredness. People with a moderate or severe TBI may have those, plus other symptoms:

  • A headache that gets worse or does not go away
  • Repeated vomiting or nausea
  • Convulsions or seizures
  • Inability to awaken from sleep
  • Slurred speech
  • Weakness or numbness in the arms and legs
  • Dilated eye pupils

Health care professionals use a neurological exam and imaging tests to assess TBI. Serious traumatic brain injuries need emergency treatment. Treatment and outcome depend on how severe the injury is. TBI can cause a wide range of changes affecting thinking, sensation, language, or emotions. TBI can be associated with post-traumatic stress disorder. People with severe injuries usually need rehabilitation.

NIH: National Institute of Neurological Disorders and Stroke

  • Brain injury - discharge (Medical Encyclopedia)
  • Chronic subdural hematoma (Medical Encyclopedia)
  • EEG (Medical Encyclopedia)
  • Head injury - first aid (Medical Encyclopedia)
  • Intracranial pressure monitoring (Medical Encyclopedia)
  • Subdural hematoma (Medical Encyclopedia)

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